December 2007 - Volume 1, Issue 6

POSTPARTUM HEADACHE SYNDROMES AMONG IRANIAN WOMEN IN TEHRAN

Simin Taavoni (1), Majid Kaveh (2), Shahram Sadeghi (3) M. Sc in Medical Education, M. Sc in Midwifery, Faculty Member & Researcher, Iran University of Medical Sciences, member of pain research group of ACECR, IUMS, IASP member, Tehran, Iran. Email:staavoni@iums.ac.ir, staavoni14@yahoo.com MD, Faculty member, Member of pain research department of ACECR, Iran University of Medical Sciences, Tehran, Iran. Email: majidkaveh@yahoo.com MD, Shahidbeheshti University of Medical Sciences, Email: shsadeghi@sums.ac.ir

ABSTRACT Post partum (postnatal) headache is a common but not entirely understood syndrome. Usually when someone speaks about benign post partum headache, migraine and tension type headache are two possible diagnoses, but we have noticed a third benign form, a new onset post partum headache. On the other hand, to the best of our knowledge, there is no report on the prevalence of post partum headache among Iranian women, also, the relationship between pre-existing headaches and post partum headache was not clear. Aims: To determine the prevalence of post partum headache and the relationship between pre-existing headaches (migraine or tension type) and the post partum headache. Also we tried to observe for the prevalence of new onset post partum headache and to determine to what extent it can be dangerous Materials and Methods: One hundred and ninety six volunteers were interviewed and examined at the first 48 hours post partum in wards of one of the well known public and educational hospitals in Tehran. (Sample subjects came from different districts of Tehran for delivering their baby). We selected by non-probability consequence sampling method. Participants were categorized into three groups: tension, migraine and new onset post partum headache. The descriptive and inferential statistics (X2) were used. Six cases were excluded so we continued the study with 190 mothers. Results: The prevalence of headache was 23.16%. Migraine, tension and new onset headache had a prevalence of: 6.84%, 10% and 6.32% respectively. There was a significant relationship between post partum headache and positive history of tension headache (p value=0.007). We found no statistically significant relationship between a history of migraine headache and post partum headache. Tension type post partum headache was the most common type. Conclusion and Discussion: The prevalence of post partum headache among Iranian women was 23.1%. About 27% (6.3% out of 23%) of the post partum headaches in our study were of new onset. There was a significant relationship between positive history of tension headache and post partum headache, but there was no relationship between post partum headache and history of migraine headache.

INTRODUCTION

Headache has troubled mankind from the dawn of civilization. The Egyptians like other ancients, believed the gods could cure their ailments and followed the instructions on papyrus. A clay crocodile holding grain in its mouth was firmly bound to the head of the patients by means of a strip of linen which bore the names of the gods. This may have given relief by compressing and may cool the scalp. (1) Sadock and Sadock said: Headaches are the most common neurological symptoms and one of the most common of the medical complaints. Every year about 80% of the population is estimated to suffer from at least one headache. (2) Approximately 35% to 40% of patients who seek treatment at headache centers suffer from daily or near daily headache. All those patients had headaches for more than 15 days a month or 180 days a year, which puts them in the category of chronic tension-type headache (CTH) according to the International Headache Society (IHS) criteria.(3) A Danish study in finding a rather large proportion of subjects with mild and infrequent (once a month or less) tension-type headache, and the prevalence of frequent tension-type headaches (more than once a month) seems to be more, about 20% to 30%. Most previous studies have confirmed that tension type headache is more prevalent in women than in men, and in both sexes, the prevalence seems to decline with age. Approximately half of patients with daily or almost- daily headache of the tension type also have episodes fulfilling criteria for migraine. The migrainous aura may also occur independently of pain. The headache phase lasts from about 30 minutes to a day; occasionally a headache becomes intractable and lasts 1 week or longer. (3) About 50% of persons who feel migraine, have less than two attacks per month, the median attack frequently being 1.5 per month. At least 10% of patients have weekly attacks; 5 % of the general populations have at least 18 migraine days per year and 1% at least one day per week. (4) Approximately two thirds of migraines occur in women. The prevalence of migraine in North America, ascertained through epidemiologic studies, is 12% to 17% in females and 4% to 6% in males. Before puberty, migraine prevalence in boys is similar to or higher than in girls; during and after adolescence, prevalence increases more rapidly in girls. Prevalence increases until age 40, after which it declines altogether, a decline that is steeper in women as they approach menopause. (5) The majority of female migrainers report occurrences of attack occur exclusively at the stage of the ovarian cycle and this corresponds to menstrual migraine. (4) Menstrual headache refers to all headaches that occur just before or during menstrual flow. Sixty percent of women who experience vascular (migraine) headaches report an increased incidence during menstruation; many women have headaches that occur exclusively with menses. (6) Pregnancy influences headache patterns, and migraine especially has been found to worsen or to occur for the first time during the first trimester of pregnancy. During the second and third trimesters, most headache sufferers show improvements in their headache. Hormonal changes may play a significant role in this process. (7) After delivery there is another change in the prevalence of headaches, it has been reported to improve (28%), worsen (56%), or not to change at all (19%). (8)

To the best of our knowledge there is no study on the prevalence of post partum (post natal) headache among the Iranian population. On the contrary, there is a paucity of reports regarding this common phenomenon and its potential risk factors in the literature. Additionally, we had noticed that some mothers experience a new onset headache after delivery and called it "new onset post partum headache".

The current study was performed to determine the prevalence of post partum headache and the relationship between pre-existing headaches (migraine or tension type) and the post partum headache. Also we tried to observe for the prevalence of new onset post partum headache and to determine to what extent it can be dangerous.

THE ECONOMIC BURDEN OF MALARIA IN PREGNANCY:

There are two possible approaches to estimating the economic burden of malaria in pregnancy. Microeconomic approaches are used to measure the effect of the disease on an individual or household, while macroeconomic approaches measure the effect of the diseases on an entire society. Taking a traditional micro level approach, economic cost can be categorized as direct, indirect and intangible and can be measured from the perspective of the government (mainly Ministry of Health ) ,and households.

The direct costs of malaria in pregnancy can be divided into:
1. the cost arising from interventions targeted at all pregnant women in malaria endemic settings.
2. the additional costs arising as a consequence of malaria infection in pregnant women .

Direct cost to the health service arising from specific interventions for preventing or treating malaria in pregnancy include the cost of the Intermittent Preventive Treatment in Pregnancy (IPTp). Direct costs associated with malaria infections in pregnant women include the immediate costs of maternal infection and also the immediate and long term costs of treating the consequences of maternal infection on the infant, most of which relates to mitigating the consequences of low birth weight. Immediate costs are those of additional outpatient consultations, hospitalization, staff time, diagnostic tests, drugs and other supportive treatment. The cost incurred by the mother (or her household) include those of obtaining additional health care such as transport, drug costs and consultation fees.(3)

MATERIALS AND METHODS

In a prospective cross sectional study, we interviewed and examined 196 volunteers - post partum women in postpartum wards of one of the Educational University Hospital of Iran University of Medical Sciences in Tehran (Year 2003). This hospital is a well known public and educational hospital in Tehran and samples came from different districts of Tehran for delivering their baby in this hospital. We selected by non-probability consequence sampling method. The interviews and physical examinations were done at day one, two and three post partum. We completed Valid and Reliable questionairre and checklist. Our inclusion criterion was normal vaginal delivery of a live infant of at least 38 weeks. We defined our exclusion criteria as:

1. History of eclampsia, pre-eclampsia or essential hypertension (Blood pressure higher than 140/90),
   
2. The presence of any sign or symptom leading the mother or her child to be considered as "high risk",
   
3. Severe physical or mental disorder,
   
4. Analgesia cases,
   
5. Unwillingness for attending the study,
   
6. Being non-Iranian.

RESULTS

The age range was between 14-44 years. The highest age group was 20-24 years (39.47%). (Table 1) Average gravidity was 2.13±1.44. (Table 2) Migraine and tension headache had a history of 27.89% and 17.38% among our subjects. The prevalence of postpartum headache was 23.16%. Migraine, tension and new onset headache had a prevalence of: 6.84%, 10% and 6.32% respectively. (Table 3)

There was a significant relationship between post partum headache and positive history of tension headache (p value=0.007). We found no statistically significant relationship between a history of migraine headache and post partum headache. Tension type post partum headache was the most common type. (Table 4)

DISCUSSION

In this study, the prevalence of post partum headache among Iranian women was found to be 23.1%. There was a relationship between post partum headache and tension headache but not with migraine headache. This prevalence is much less than that reported by Stein et al (9). This difference could be a result of our failure to extend the interview and physical exam to the 6th day post partum as it had reported the post partum headache to be most frequent on days 4-6th post partum; however, this finding was not reported by an independent study. (10) Stein et al have only examined 71 women, much less than our study population. (9) Adimna et al reported the prevalence of post partum headache to be 24.3% which is very close to our observation (10). Arreguie et al (1991) indicated the highest rate of migraine in 50-59 groups (38.1%), Stewart et al (1996, 1992) showed the highest rate of migraine in 18-25 age groups (22.7%), and in 30-39 age groups (28.7%). (11) In this study we found the highest group of postpartum headache in the 20-24 age groups (34.09%), which was 8.78% of the entire samples.
About 27% (6.3% out of 23%) of the post partum headaches in our study were of new onset. This percentage constitutes a great fraction of the post partum headache syndromes and we proposed that this finding may be due to a rapid change in hormonal levels. Dangerous organic diagnoses such as subdural hematoma, stroke, or cerebella infarction (12, 13, 14) were made for none of the mothers.

CONCLUSION

In this observation we found the prevalence of post partum headache among the Iranian women to be 23.1%. There was a significant relationship between positive history of tension headache and post partum headache, but there was no relationship between post partum headache and history of migraine headache. We concluded that a positive history of tension headache can be a risk factor for developing post partum headache that seems to be a natural finding, as the delivery is a stress for the mother. In this study we had ruled out the mothers with a "high risk child" to eliminate this extra stress but it can cause a potential bias and lead to a low incidence.
A diagnosis of new onset post partum headache was made for 27% of the post partum headache group; fortunately none of them were diagnosed to have malignant diseases such as cerebella infarction.

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